New study shows barriers in diagnosis and treatment of low testosterone in middle-aged men

TD is a neglected area of health for men but one that can severely negatively impact men’s general well-being and their mental health. The paper also reports that a lack of awareness and knowledge of the range of symptoms of TD, combined with the stigma and embarrassment associated with the condition, is inhibiting open, proactive discussions between men and GPs and limiting diagnosis. The paper also found that there are often delays in diagnosis because men do not think to seek help or advice for non-specific symptoms such as fatigue, low mood or decreased muscle mass, and some GPs do not think to check testosterone levels when met with these symptoms.

The aim of the interview-based study was to gather a complete, holistic picture of the barriers preventing men with symptoms from being diagnosed and accessing support and appropriate treatment. It involved in-depth, 60-minute interviews conducted with 20 men aged 45 to 62, 30 GPs and 10 endocrinologists from across the UK. Data from the interviews was then analysed and cross-referenced to identify key issues and how they might be addressed.

This paper follows a recent topical spark of interest in the "male menopause", however this is an unhelpful term as the label is misleading because it suggests the symptoms are the result of a sudden drop in testosterone in middle age, similar to what occurs in the female menopause, which is not the case. Although testosterone levels fall as men age, the decline is usually steady at about 1% a year from around the age of 30 to 40. However, age related TD is more common in men aged over 40 and can have a considerable impact on quality of life, well-being and long-term health outcomes. The estimated incidence of TD in men aged 40-70 years with symptoms varies between 2% and nearly 6%.

The symptoms of TD can include mood swings and irritability, depression, loss of sex drive, erectile dysfunction, loss of muscle mass and reduced ability to exercise, fat redistribution, such as developing fat around the abdomen or increased breast tissue in men (gynaecomastia), a general lack of enthusiasm or energy, poor concentration and short-term memory, difficulty sleeping (insomnia) and increased tiredness.

The results of interviews revealed barriers at every point in the pathway for men to access healthcare for testosterone deficiency. There is a lack of awareness of the symptoms among men and GPs, a shared reluctance to broach “embarrassing” subjects such as reduced libido or erectile dysfunction, and a lack of knowledge and confidence among some GPs in how to manage patients. Differing attitudes and beliefs among GPs and endocrinologists around the definition of testosterone deficiency and at what testosterone level treatment should be initiated also mean there is continued variation in treatment approaches, despitethe availability of guidelines. Despite guidelines recommending investigation of testosterone levels in men with symptoms and those considered at higher risk, many men with symptoms of TD are still undiagnosed and untreated.

The perspectives of men

For the 20 middle aged men interviewed for this study, researchers found that a sense of stigma, embarrassment and “machismo” often meant that men were reluctant to discuss symptoms with their doctor. Men reported a slow, gradual onset of non-specific issues like fatigue, loss of energy and loss of muscle strength, which were often normalised or misattributed to age, stress, hard work, exercise or minor illness. The men did not necessarily equate loss of libido or erectile dysfunction to low testosterone, and very few were aware of the link between these sexual symptoms and other symptoms. All men were uncomfortable discussing their sexual symptoms with their doctor; the loss of libido or erectile dysfunction were the key triggers for seeking help, usually driven by a need to ‘fix’ this issue for the sake of their relationship. Some men reported that getting a diagnosis of testosterone deficiency could take several months or years. Limited GP consultation time also made it difficult to have a meaningful conversation, especially when they need to overcome embarrassment – and feeling rushed meant that they may not report all symptoms.

The perspectives of GPs

Interviews with 30 GPs revealed a variation in care, with three clear groups of GPs showing differing approaches to the diagnosis and management of testosterone deficiency: a small number of specialist GPs who believed TD is clinically or psychologically important and generally diagnosed and treated it themselves; a majority of GPs who were less knowledgeable but believed testosterone deficiency should be treated – these GPs expressed concern about potential risks and always referred patients to endocrinologists for confirmation of diagnosis and treatment initiation; and lastly, a small number of GPs did not consider testosterone deficiency to be clinically important, and were not convinced about the necessity for treatment.

The perspectives of endocrinologists

The 10 endocrinologists interviewed for this study were generally positive about treatment, recognised testosterone deficiency as a clinically important condition requiring treatment and believed that treatment should be initiated as soon as possible. The researchers also found that endocrinologists often had to manage patient expectations around treatment: in patients diagnosed with low testosterone, endocrinologists will need to identify the root cause, which may involve underlying conditions such as diabetes or obesity or be a consequence of other medication.

The findings also showed there was variation in the treatment thresholds used by different clinicians. Someendocrinologistsbelieved that the majority of straightforward cases should be managed in primary care with advice, if required.

Dr Janine David, GP and Secretary of the British Society for Sexual Medicine, and co-author of the study explained:

“Testosterone deficiency is complex, poorly understood and significantly under-diagnosed, yet it can have a huge impact on a person’s relationships, well-being and long-term health. This research shows how the cards are often stacked against men who need timely diagnosis and treatment.

“Like menopause care, we need to start talking more openly about testosterone deficiency as a medical condition, bringing it out of the shadows so that more men understand their symptoms and feel able to come forward for treatment.

“As we do so, it is also important we improve the consistency and standard of care across the NHS, raising knowledge and awareness among clinicians and developing clearer guidelines on the treatment and management of this condition so that we can offer men the right support.”

The paper, funded by Besins Healthcare UK, highlights the need for men to be more proactive about seeking medical advice and contacting their GPs, if they are showing symptoms of TD. In addition, the insights from GPs show the need for some GPs to upskill on TD and be more familiar with the existing guidelines in order to be able to help more men presenting with symptomatic TD. And finally, there is an opportunity for endocrinologists to align on treatment to ensure more equitable access for men with TD to improve patient outcomes.

‘Stronger Voices’ public awareness campaign

Any men that may be experiencing any of the symptoms of TD should speak to their healthcare professional. To empower men and their partners to understand the condition, identify potential symptoms and take action to address their well-being, Besins Healthcare UK has created a TD public-education website as part of its ‘Stronger Voices’ public awareness campaign. Multi-language resources include the internationally recognised Androgen Deficiency in Aging Males (ADAM) questionnaire and a downloadable guide to starting a conversation with their doctor. The website can be accessed at https://www.strongervoices.co.uk.

TD diagnosis. Please note many of the symptoms of TD could be attributed to other conditions, therefore, it is important that men speak with their healthcare professional about any concerns they may have about their health. Having these symptoms alone, without a test, is not a diagnosis of testosterone deficiency.

The study was commissioned and funded by Besins Healthcare UK.

The co-author of the paper, Dr Janine Davidreceived an honorarium from Besins Healthcare UK relating to the design and execution of this study but received no payment for authorship of this paper.

About Besins Healthcare UK

Besins Healthcare is a specialist company with a strong family heritage that has dedicated over 50 years to understanding the impact of hormones in the fields of gynaecology, andrology, fertility, obstetrics, and endocrinology. By working with passion and commitment we develop and deliver hormone therapies and solutions to people with hormone imbalance in the UK and Ireland. Our aim is to empower those with life-impacting hormonal conditions, enabling them to lead fulfilling lives both now and in the future. Our patient-centric ethos is: “By your side, for life”. www.besinshealthcare.co.uk